I’ve spent the last 15 years in the tech startup community including several early stage ventures with successful exits in the healthcare space. I'm also a Top Writer on Quora (2012 and 2013) for several healthcare specific topics. I'm likely to include film references and quotes as in "All of life's riddles are answered in the movies." Twitter handle is: @danmunro

Healthcare's Big Problem With Little Data

Every year, the analyst firm Gartner publishes between 90 and 100 “Hype Cycles” with insight on about 1,900 different technologies. The Hype Cycle above is the one for Emerging Technologies for 2012 (published in August) and shows “Big Data” heading toward the “Peak of Inflated Expectations.”

According to Gartner, Big Data has about 2-5 years before reaching it’s ”Plateau of Productivity.” That’s the enviable point at which a technology finally delivers predictable value. The promise of Big Data, of course, is a treasure trove of high value across many industries – including healthcare. Everything from predictive and prescriptive analytics to population health, disease management, drug discovery and personalized medicine (delivered with much greater precision and higher efficacy) to name but a few.

Like many emerging technologies, the future here is brilliant and chock-full of headlines highlighting all the rich rewards ahead. In the meantime, however, ”little data” in healthcare continues to give us all peptic ulcers.

While it lacks any formal definition, one way to think of little data is anything that operates at the unit level. One account, one patient, one customer, one transaction or one record. Healthcare billing data has evolved sufficiently that much of it has been standardized and automated – but clinical data is still years behind. Clinical data at the unit level is chaotic and dysfunctional because it’s not easily transferable or usable outside of the system that first created it. In a world of competing financial interests and an increasingly mobile population – every patient encounter represents an opportunity for technology vendors to lock-in providers.

Word Processing had an equally chaotic start as well. You could export/import between competing word-processing applications, but the steps weren’t easy – or seamless. That’s the same dilemma facing the entire Electronic Health Record (EHR) software industry. Simply adding the word “cloud” to the marketing material (and pricing scheme) doesn’t change the underlying dysfunction. In fact, it’s often just a way to capture the allure of a new technology to sell antiquated ideas around the profitability of data that’s effectively held at ransom.

It’s a classic innovator’s dilemma. On the one-hand, in order to support early (and often significant) development costs, commercial solutions need to be proprietary and protectable The challenge in healthcare is that the proverbial other hand is data that literally and figuratively represents our lives as patients inside our ossified healthcare system. Historically, the crutch that many software vendors have relied on is the format of the data itself. The sales process is designed to glamorize the feature and functionality – while obscuring the fact that the data format is 100% proprietary. Through the years, this cycle of customer acquisition and lock-in has now been repeated hundreds of times.

By at least one estimate (here) there are now about 500 independent EHR vendors. Out of that large group is a subset of about 400 with at least one customer that has applied for Federal stimulus dollars through the labyrinthine process of meaningful use attestation. That would suggest a “first-cut” of about 100 vendors who made some commitment around certification – but have no reported customers (at least to date). That’s a staggering number of single-purpose software vendors for any industry to support – even bloated healthcare. The simple fact is it can’t. While there have been a few high-profile cases of EHR vendors shutting down, this last week was the first high-profile example of a vendor that was effectively decertified by the Feds for both their “ambulatory” and their “inpatient” EHR products. From the HHS.gov website last Thursday:

“We and our certification bodies take complaints and our follow-up seriously. By revoking the certification of these EHR products, we are making sure that certified electronic health record products meet the requirements to protect patients and providers,” said Dr. Mostashari. “Because EHRMagic was unable to show that their EHR products met ONC’s certification requirements, their EHRs will no longer be certified under the ONC HIT Certification Program.”

One vendor out of 400 isn’t a trend, but it does suggest that as the rigors of meaningful use and certification increase, more and more vendors will likely not survive. With almost 400 EHR vendors and the certification process still in its infancy, we can expect a lot more chaos in this ecosystem of competing interests. There may come a point when a provider sees more value in advertising their EHR affiliation than ER wait times.

Big Data is clearly where all the excitement and headlines are, but it’s the little data that is likely to have the most effect on our individual healthcare. That is at least until Big Data gets well beyond its “peak of inflated expectations” and closer to its “plateau of productivity.” The question then is – which vendors are likely to be around in 2-to-5 years?

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Yes I didn’t treat that de-certification in Santa Fe Springs as a big deal as nobody had attested yet and sure there will be a few more. I go back to the early days of EMRs in having written one myself. It grew quickly with technology and was an old VB6 person and made a choice when all moved to the web. First it was an old technology and I had choices to either go up to dot net or do something else.

For me “do something else” was my answer as a lone developer I realized that was going to be no longer and I would die at the keyboard with the amount of work and so on and no big bank roll, and I had not been out there very long so converted the few clients I had to other systems and became a consultant who blogs:)

Before the government became involved it was the wild west and we saw some come and go then, watched a couple vendors hold medical records hostage until they paid their bills and so on. It was wild in the early days and folks like Cerner were around, GE was busy building Centricity for a mention of the “big guys” if you will and there were many more as well.

Certification was also a big reason for me to drop out as well, again didn’t have the big money to stay in but at no time have I ever regretted the learning experience I gained and I used that with speaking of “data mechanics” today as prior to being a programmer I was outside sales rep for years in another industry so you see a lot of “hybrid” comments when you read of mys stuff, which is not a bad thing other than it makes my brain hurt a lot when trying to put it out there for the layman to hopefully appreciate:)

There are various types of medical record companies and I know everyone envies Epic but if you look at CEO Judy’s background, she wrote code and you can’t say that for too many of the system out there. It’s like Bill Gates with his background, hands on and knowing mechanics is always a winner with foreseeing and projecting as when you know the processes and can simulate some type of a time frame against those that don’t, there’s no comparison. I’m not going to comment on pricing at all as that’s an issue to where time spent writing code in house versus buying up another company is a whole different discussion for companies like Allscripts and others.

It depends a lot on the technologies being integrated too, as I keep saying to all “the short order code kitchen burned down years ago and there was no fire sale”. In other words complexities today along with the aggregation of data availability out there today makes the development of medical records much more difficult and add the payer aspect in here too and yes indeed the search for value in the eyes of “which beholder” (payers or users) is up for discussion daily and I haven’t even mentioned the patient yet, but they are in there too as they should be too:)

Thanks for this provocative piece, Dan. I agree that healthcare faces many more challenges before the hope of big data becomes a reality. I’m sure the weeding out of less-than optimal electronic health record providers will continue, however that concerns me if choice of quality products and competition is also diminished. For instance, Epic has taken a major share of the large healthcare electronic record market as a clear dominant player. Do you really think that they will be held to the same standards as the smaller players? No, more likely they will be setting the standards that the government adopts, or at least the government won’t look too long and hard at any deviations Epic products exhibit from requirements they are setting. So is that fair, or are we essentially creating a regulated monopoly which will increasingly have the government trying to control what it probably should not be involved in at all.

I think it might be better that we step back from meaningful use requirements and focus on quality of care requirements and reimbursement standards that have no direct linkage to the electronic health record system, but rather reward healthcare providers for the best care independent of the system that they choose. Then we can watch the EHR providers compete to support those right-directed incentives.

I’m far less concerned about Epic than I am smaller vendors that will leave providers (and patients) holding the proverbial bag. The larger issue (that I see) is the fragmented, piecemeal approach to healthcare that’s reflected by the sheer # of EHR vendors. The whole thing is really inefficient – both clinically and financially. Big topic – and I do intend to write more about this – including Epic – in the not too distant future. Thanks for the comment.

Whilst Big Data is the latest buzz word, the reality is that healthcare to individuals is delivered with little data, because to date we have not found a system that works better than one to one care. Whilst I agree that the current method of delivering healthcare is not perfect, it has been refined over thousands of years of doctor-patient interaction. Until such time as “big-data” or HIT can demonstrate similar effectiveness most doctors will continue to practice “little-data” medicine.

I note the other health related activity on the hype chart is home health monitoring. Here is another example of collecting data for data’s sake, without the scientific rigour we see in other areas of medicine, and then being disappointed by the results. Home monitoring is the “big-data” of community healthcare, but the reality is that just collecting data without clinical models that can utilise it is a recipe for failure. The “little-data” hidden in the plethora of data released by such systems is what doctors have used for generations to deliver good care. Sometimes people fall through the holes when we just rely on “little data” but to date the evidence suggests that by over reacting to too much “big-data” doesn’t necessarily improve health outcomes,and potentially blows out the costs of delivering the service.

Nice succinct article. I’ve discussed a couple of the key points mentioned in this article as well. Cloud Computing is a marketing term referring to technologies and capabilities that have been around for several years. It in itself is not a solution. The key road blocks and challenges for moving forward and leveraging technology is integration. Especially with the increasing number of EMR vendors, this will sure increase complexities. I’ve been involved in multiple EMR projects over the years and integration with other vendors was always a challenge and it often delays projects for weeks, months and years.

Larger vendors are typically at an advantage as some of their ubiquitous systems often become the de facto standards. The onus is then on the smaller vendors to comprise and ‘bend’ in order to integrate with the larger vendors.

Agreed. But then the question is – do we legislate a standard (much like which side of the road to drive on)? Or do we wait for an intensely competitive industry to cooperate with each other? That’s the debate ahead I see.